Lateral Condyle Fracture - Pediatric

Topic updated on 03/12/16 12:27pm
  • Fractures involving the lateral condyle of the humerus 
  • Epidemiology
    • incidence
      • 17% of all distal humerus fractures in the pediatric population
    • demographics
      • typically occurs in patients aged 5-10 years old
    • location
      • most commonly are Salter-Harris IV fracture patterns of the lateral condyle 
  • Pathophysiology
    • mechanism of injury
      • pull-off theory
        • avulsion fracture of the lateral condyle that results from the pull of the common extensor musculature
      • push-off theory
        • fall onto an outstretched hand causes impaction of the radial head into the lateral condyle causing fracture
  • Prognosis
    • outcomes have historically been worse than supracondylar fractures
      • articular naturemissed diagnosis, and higher risk of malunion/nonunion
Milch Classification-controversial
Type I

Fracture line is lateral to trochlear groove

Type II Fracture line into trochlear groove
Fracture Displacement Classification-Weiss et al.
Type 1 <2mm, indicating intact cartilaginous hinge

Type 2 >2 mm < 4 displacement, intact articular cartilage on arthrogram
Type 3 >2-4 mm,  articular surface disrupted on arthrogram
  • History
    • fall onto an outstetched hand
  • Symptoms
    • lateral elbow pain
    • mild swelling
  • Physical exam
    • inspection
      • exam may lack the obvious deformity often seen with supracondylar fractures
      • swelling and tenderness are usually limited to the lateral side
    • motion
      • may have increased pain with resisted wrist extension/flexion
      • may feel crepitus at the fracture site
  • Radiographs
    • recommended views
      • AP, lateral, and oblique views of elbow
        • internal oblique view most accurately shows maximum displacement and fracture pattern 
    • optional views
      • contralateral elbow for comparison when ossification is not yet complete
      • routine elbow stress views are not recommended due to risk of fracture displacement
    • findings
      • fracture fragment most often lies posterolateral which is best seen on internal oblique views
  • CT scan
    • indication
      • improved ability to assess the fracture pattern in all planes
    • findings
      • CT has limited ability to evaluate the integrity of articular cartilage
      • may require sedation to perform the test
  • MRI
    • indication
      • provides the ability to assess the cartilaginous integrity of the trochlea
    • findings
      • increased expense
      • may require sedation to perform the test

Pediatric Elbow Injury Frequency
Fracture Type
% elbow injuries
Peak Age
Requires OR
Supracondylar fractures
Radial Head subluxation
Lateral condylar physeal fractures
Medial epicondylar apophyseal fracture
Radial Head and Neck fractures
Elbow dislocations
Medial condylar physeal fractures

  • Nonoperative
    • long arm casting
      • indications
        • only indicated if < 2 mm of displacement, which indicates the cartilaginous hinge is most likely intact
        • sub-acute presentation (>4 weeks)
      • technique
        • cast with elbow at 90 degrees and forearm supination
        • weekly follow up
        • radiographs out of cast may be useful
        • total length of casting is 3-7 weeks
  • Operative
    • CRPP
      • indications
        • somewhat controversial, but Weiss et al suggest fractures with < 4 mm of displacement have intact articular cartilage and can be treated with CRPP
      • technique
        • closed reduction performed by providing a varus elbow force and pushing the fragment anteromedial
        • divergent pin configuration most stable
        • third pin may be used in transverse plane to prevent fragment derotation
        • arthrogram used to confirm joint congruity
    • open reduction and fixation
      • indications
        • if > 2-4mm of displacement
        • any joint incongruity
        • fracture non-union
      • technique
        • direct lateral approach
        • avoid dissection of posterior aspect of lateral condyle (source of vascularization)
        • percutaneous or subcutaneous pins may be used for fixation
        • single screw may also be used with non-unions +/- bone grafting 
  • AVN
    • posterior dissection can result in lateral condyle osteonecrosis
    • may also occur in the trochlea
  • Nonunion/malunion
    • caused from delay in diagnosis and improper treatment
    • may result in cubitus valgus and tardy ulnar nerve palsy   
  • Tardy ulnar nerve palsy
    • slow, progressive paralysis of the ulnar nerve
    • caused by stretching of the nerve, as is seen with cubitus valgus
    • usually late finding, presenting many years after initial fracture
  • Lateral overgrowth/prominence (spurring)   
    • in up to 50% of cases regardless of treatment, families should be counseled in advance
    • lateral periosteal alignment will prevent this from occurring
    • presence of spurring is correlated with greater initial fracture displacement
  • Growth arrest with or without angular deformity
  • Unsatisfactory appearance of surgical scar
  • Late elbow presentation or deformity
    • cubitus varus deformity is most common in nondisplaced and minimally displaced fractures
    • cubital valgus less common, but more likely with significant deformities that cause physeal arrest 
    • controversy whether to treat subacute fractures (week 3-12) nonoperatively or surgically
    • most deformities can be corrected after skeletal maturation with a supracondylar osteotomy


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Qbank (8 Questions)

(OBQ11.192) A 36-year-old male presents for evaluation of left hand weakness. A current clnical photograph of his hand is shown in Figure A. His medical history is significant for the elbow injury shown in Figure B, which was treated non-operatively twenty-eight years previously. Current radiographic evaluation of the patients elbow will most likely reveal what deformity? Topic Review Topic
FIGURES: A   B        

1. Cubitus valgus
2. Avascular necrosis of the lateral fragment
3. Fishtail deformity of the distal humerus
4. Fracture nonunion and a normal carrying angle
5. Myositis ossificans

(OBQ10.209) Nonunion following a pediatric lateral condyle fracture has been associated with which of the following? Topic Review Topic

1. Ulnar nerve palsy
2. Radial nerve palsy
3. Heterotopic ossification
4. Parsonage Turner syndrome
5. Cubitus varus

(OBQ09.186) An 8-year-old boy falls on his right upper extremity and presents to the emergency room with the radiographs shown in Figures A and B. He has exquisite tenderness to palpation along the lateral aspect of his elbow. What additional radiographic view will likely demonstrate the maximum degree of fracture displacement? Topic Review Topic
FIGURES: A   B        

1. External oblique radiograph
2. Internal oblique radiograph
3. Anteroposterior in maximum flexion
4. Anteroposterior in maximum extension
5. Lateral in maximum extension

(OBQ08.35) A 7-year-old girl undergoes open reduction internal fixation of a displaced humeral lateral condyle fracture. Dissection around which portion of the fracture fragment should be avoided to protect its blood supply? Topic Review Topic

1. medial
2. lateral
3. superior
4. anterior
5. posterior

(OBQ07.169) Figure A shows the radiograph of a 6-year-old girl after a fall on the playground. What is the most appropriate course of action? Topic Review Topic
FIGURES: A          

1. Observation with treatment in a sling
2. Closed reduction and long arm casting
3. Closed reduction percutaneous pinning with k-wires
4. Open reduction internal fixation with k-wires
5. Open reduction with plate fixation

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